Back to Basics

'Precisely
because we have no cure far AIDS, health services
must resort to the basic principles of
primary health care: more than ever
before, health promoters at all levels
need to work with communities - jointly
planning education and counselling
campaigns and developing a
community's capacity to make
informed choices about health related
behaviour. This is an enormous challenge - a community-based
approach is not the usual outcome of
conventional health training.'

This concern - expressed by a
doctor working for an international development organisation - is one
shared by all those involved in AIDS
prevention and control. Health education
about AIDS should not just involve
the production of leaflets and posters, radio and television programmes -
although
these materials are obviously
important. Persuading people to
change their sexual behaviour on a
wide scale (central to AIDS prevention
and control) is immensely difficult to
achieve, challenging our sense of privacy
and culture; it takes more than
just giving people information. Education must be a two-way process and
should enable people to make
choices about their lifestyle, based on
an awareness of the full implications of
AIDS.

Counselling
To achieve this, on element of 'counselling'
is needed in health education
strategies. Counselling
involves the sensitive development of
a relationship between the 'counselor'
and the selected individual or
group. The term 'counselling' does not
just refer to the work of trained specialists - many countries do not
have the resources far this. In most communities there are individuals whose role
in society has already
helped them to acquire 'counselling'
skills, for example, religious leaders
and traditional healers. Such individuals
should be encouraged to take an
active part in HIV counselling. The success
of all AIDS education campaigns
will rest on a trusting relationship between
the health educator and the
community. Building such a relationship is closely related to the principles,
of primary health care: where working
closely with selected populations and their leaders is of paramount
importance.

Objectives
Health education and 'counselling' will
need to focus on different aspects of
sexual behaviour and working practices,
depending on the selected
'audience'. Broad-based counselling and health education objectives are
summarised below:

Health care providers: to be able
to promote awareness of modes of
transmission; provide guidelines about
'safer sex' (see page 4) and other
advice to back up written materials on
risk behaviour; recognise clinical
symptoms and take sensible precautions
when caring for AIDS patients
(see AIDS Action issue
1); to follow
proper sterilisation procedures when
giving injections.

Traditional health practitioners: to
use properly sterilised equipment for
every injection and any other action
which involves piercing the skin.

General public: to increase knowledge
about safer sex practices
(above all, to avoid having many sexual partners), to demand use of sterile
needles, syringes when receiving injections, and blood that has been
screened for HIV when receiving
blood transfusions. To avoid tattooing, scarification and circumcision where
instruments are not properly sterilised.

Persons infected with HIV: here the
role of counselling, as opposed to simply handing over information about 'do's' and 'don'ts', is absolutely
crucial.

An infected person will need personal
and practical support from the
health services and the community.
Such individuals are then more able to
cope with the responsibility of helping
to ensure that others do not become
infected e. g. by not donating blood
and by strictly adopting safer sex
practices, or sexual abstinence.
Self-help support groups for HIV infected persons and their families have been enormously successful in a
number of countries. They should be encouraged.

Further training
Worldwide, there is a growing need for further training to promote counselling skills, and greater awareness of
how behaviours are changed. Continuous discussion on the planning,
implementation and evaluation of health education campaigns is particularly valuable.
AIDS Action aims to
provide a forum for discussing AIDS
education activities. All our readers
are encouraged to contribute articles
to voice their opinions.

Sex education in the Cameroon

How do adolescent boys and girls learn about sexual
matters? Who should give sex education to teenagers?
How should this be approached? A recent study in the
Cameroon, carried out by Drs Esther Gwan and Jenny
Almeida, has successfully identified ways of starting
discussions with teenagers about these, and other,
questions which may be useful elsewhere as a part of
planning AIDS education.

'Many people don't talk that easily about sex' Dr Gwan
told AIDS Action. 'When you meet a
group of children, and you say you are going to talk about sex, it's as if you'd
just dropped a bomb. But by the end of the lesson nobody wants to leave the class. It's a very exciting position to
be in. The children are openly talking
about very important issues.'

Four key methods were used,
which effectively obtained information
from 230 schoolchildren (aged 11, 16
years) about their sexual behaviour,
knowledge of conception, contraception and sexuality transmitted diseases
(STDs). Slightly more girls were involved in the study than boys, and
both sexes were mostly aged 12-15
years. All were GCE O' Level students
selected from two bilingual schools in
Yaounde. Since Cameroon is a bilingual
country (English and French) these
schools included the two main cultural groups in the country.

Methods

The 'agony aunt' letter (in this case 'Dear Tatta Christine'). This
letter express a problem relating
to a teenager's sex life, which
is open for discussion among
children in a class setting. Children were encouraged to take the role of the
adviser, Tatta Christine (see figure one) and to write a letter in
reply

Children were encouraged to fill in missing information on a line
drawing (see figure two relating
to pregnancy, e. g. where the
mother carries her baby when
pregnant, how the baby grows,
and how the mother feeds the
baby in the uterus. The sessions
were followed by feedback from
the children and any specific
questions or doubts were discussed
and clarified.

Children completed a questionnaire asking them to state whether
they strongly agree, agree, slightly agree, or disagree with
statements made about aspects of sexual behaviour.

A second 'secret', questionnaire was handed out to children who
completed it knowing that their responses are 'secret' since they do
not add their name to it.

Sessions with all age groups
resulted in animated discussion and
interest in the topics despite some
initial shyness (particularly amongst 11-12 year olds).

During the study, 130 parents and
110 teachers of 11-16 year old students
were interviewed, as well as 26 health workers involved in clinics far family
planning and sexually transmitted diseases.

Dear Tatta Christine,

I hope you can help me with this terrible problem. Some
friends and I from the school have been going out and having
some fun with girls of no very good reputation. Do you know
what I mean? One of my friends was diagnosed as having a
venereal disease. I am really concerned about myself. My
family are Christians. I don't know who I should ask
for help. If I had a venereal disease I would feel very
embarrassed...

Desperate,

Results
'Dear Tatta Christine':
The letters related to two different
topics - premarital sex and fear of
sexually transmitted disease. When
children were asked what they would
do in the same situation they often replied
that they would consult their
friends, especially those with experience. For most of the children, their
peers (friends) were the main source of information.

Outline Drawing

Most of the children knew that a baby depends on its mother to develop
and grow. What was not very clear to them was the exact nature of this connection - some children connected the baby to the
mother's intestines.

Agree/disagree
statements:
Both boys and girls said that 'love is
more important than sex' but that 'sex
is necessary before marriage to have experience
and to know the other one
better.' Religious and moral values were
important, but did not seem to greatly
affect decisions where personal
sexual behaviour was concerned.

Secret questionnaire:
This aroused much interest among the teenagers:
'it's a questionnaire and we
don't need to write our names? I
like this!' Obviously, it was still difficult to
guarantee that answers were entirely
truthful.

The questionnaire revealed that
24 per cent of the teenagers had experienced
sexual intercourse. The
most common age for starting sexual activity
for girls was 13 and for boys 15.
Forty-eight per cent of the children had
heard about contraceptives (for 45
per cent this meant oral contraceptives).
Twenty-seven per cent said that contraceptives
were dangerous and could
permanently 'stop people from
having babies'.

Many parents thought their children started sexual life
at
an older age than
actually indicated

General indications
Despite the limited amount of accurate
knowledge these teenagers had
about sexual matters, the study shows
that they were able to confront real-life
situations concerning adolescent sexuality.
Contrary to the views of adults, i.e. that 'children should not talk about
such things... they are too young to understand' the teenagers initiated
important discussions about their
sexuality.

Interviews with parents revealed that most thought their children
started
sexual life at an older age than indicated
in the teenage study. Dr Gwan
noted: 'both parents and teachers felt
very strongly that any method of birth control should not be taught... they
were worried their children would
begin experimenting with sex. However, I feel that withholding information from
teenagers makes experimental sex more likely - and more dangerous.'

Parents' role
'There has to be some way of overcoming
sexual inhibitions between parents and children. I think parents should be given advice on how to
approach the subject.' Parents and
children do not communicate about
sexual matters. It is only the mother
who seems to fulfill any sex education
role, and this is usually of a moral, not
a practical, nature.'

The study illustrated the
vulnerable position teenagers
find themselves in

The study illustrated the vulnerable
position teenagers find themselves in, at a time when they need information
about sexual matters they are
often denied it. Interviews with
teachers revealed that schools are not
providing enough information about this subject and teachers lacked
knowledge about sex education methods. Of the very small amount of
sex education that is available in some
schools, much of it is not providing the
information these teenagers said they
wanted. Ninety per cent were interested in knowing about safer sex,
and, about STDs, both of which are rarely taught.

Health workers revealed that the
health services are not reaching the
young - services are only available when it is too later e. g. when unwanted
pregnancies or venereal diseases have already occurred.

National campaign
The
mass media has influenced a high
proportion of young people in
Yaounde: the majority of the teenagers interviewed mentioned prostitutes
and promiscuous people as high
risk groups for AIDS infection.

Worldwide
more than one person in five is a teenager...effective AIDS health
education for adolescents is crucial

But Dr
Gwon commented: 'from a doctor's
point of view, I don't think there has
been anything very clear about the biological facts about the virus...it is useful that people understand that
AIDS is terrible, bur the context in
which AIDS is contracted should be
better defined.
'Everyone has heard about AIDS...there has even been a popular
record made about AIDS by a famous Cameroonian pop star. But sex education about condoms is viewed with
a lot of scepticism. At the moment, the government campaign does not put an emphasis on using condoms.
It is a
moral dilemma for the government as well.'

Worldwide more than one person in five is a teenager. An effective education and service programme is
crucial for adolescents in any AIDS
control programme.

As Dr Almeida stressed: 'the
young should be targeted, since they are the most at risk - because of their
ignorance, and the number of years of
sexual activity ahead of them.'

This article is based on an interview
with Dr Esther Gwan and on Dr Almeida's
report on their joint study
entitled: Methods for Starting Discussions
with School-age Cameroon Teenagers, submitted to the Institute
of Child Health, University of London
(1987).

Guidelines for action

This article provides general advice and guidance for those planning health education and counselling activities on AIDS.

In the absence of a cure or vaccine,
changing behaviour through education is the most important way to
prevent and control the spread of AIDS. Firstly, however, it is important to clear about what actions to promote.
On the basis of current knowledge,
actions for reducing the risk of HIV transmission through sexual behavior,
our are summarised below:

Keeping to one sexual partner, or limiting the number of partners to
as few as possible;

avoiding sexual intercourse with
someone who has had many sexual partners;

practising 'safer' sex (i.e. avoiding
penetration by the penis, of the vagina or anus, avoiding mouth-to-genital contact, avoiding
sexual intercourse with many partners, and/or using a condom
during penetrative sex).

Work through local groups

People will usually be more easily convinced,
and more willing to change
their behaviour, if approached by a
trusted member of their own group
rather than an outsider. Encouraging
the direct involvement of your selected
audience in the planning and implementation
of health education
campaigns is essential.

Identify selected groups in the
community, for example, adolescents,
men and women working
away from home, prostitutes.

Find out which people have influence
and are respected within
each group. Do this by looking at
the political, cultural and social organisations
that exist. Or you
could organise a health education
competition (offer a prize-winning incentive) in order to identify the
most talented and highly motivated
individuals - who will the,
make much better educators than
outsiders. This is particularly true
of children and adolescents, who
could design more appropriate teaching materials, and activities, for other youngsters.

Find out what people feel and think about AIDS, and safer
sexual
behaviour. Do they think behaviour
can be changed? Identify
any incorrect beliefs that you will have to try and change. What beneficial
beliefs and/or traditional
practices could you reinforce and
build upon?

Provide simple training and try to
find funds to provide their expenses and,
if possible or appropriate,
provide a small payment.

Make your advice realistic and acceptableConsideration of cultural, moral, political and religious attitudes and practices are important in developing
health education messages*.

Meet local politicians, parents, religious and other leaders and
health workers to discuss the
moral issues and agree on acceptable and effective messages

Choose messages that are relevant to current social behaviour, so
that people take them seriously.

Do not pass moral judgments on
the sexual activities of the communities you work with. Where
possible, concentrate on making
existing sexual practices safer.

Individual and small group counselling is usually the most effective
way of changing people's behaviour.
You can make the message
specific to the needs of a
particular audience. Check that
they have understood by asking
questions. Person-to-person methods are better for explaining
information, relieving anxieties
and helping people make decisions
about their own sexual and
other risk behaviour.

Help to make any talks/discussions
more interesting with well
chosen visuals, such as large
drawings, cartoons, slides or pictures
cut out of magazines.

Use the traditions of drama, storytelling,
songs or other oral communication
methods. Puppets are
a good example; they can be
made cheaply and are fun to use.
It is also possible to discuss sensitive
and potentially embarrassing
topics - that would not be acceptable in talks or drama - through
the use of puppets (see
Puppets for Health manual, listed
under Resources, page 7).

Give local entertainers the basic
background on AIDS and let them
use their experience to adapt the
message to their own words and
music.

Work with local groups in the production
of leaflets which are
appropriate to the needs and
practices of each group. Leaflets
are a useful back-up to counselling
sessions. Make the language
simple and use pictures. Try out
draft versions to make sure that
they are understood. Always include
an address where people
can go for further information.

Only use posters as part of a
broader health education campaign.

Use the mass media - such as the
local radio - for spreading simple
messages and always make
sure that you tell people where
they can get further information
and advice.

Campaigning on use of condoms
In areas where there is opposition to family
planning, it is important to emphasise
the disease prevention role of condoms.
Another reason why condoms are often
not popular, is that people may not have
had much opportunity to try them out and
become used to them.

Do not begin an education campaign
based around use of condoms
until you have ensured that there is
an adequate supply of condoms available
at an affordable price. Contact
your country (or regional) World
Health Organisation representative,
or other international aid agency, or
family planning clinic, to find out
about condom availability in your
area.

Mobilise all possible outlets including
shops, supermarkets, factories, bars and discos, to make condoms
easily accessible to all the key
groups in the community.

Encourage shopkeepers to display
condoms where people can easily
notice them, and provide educational
back-up for them and their
customers through radio promotions,
posters and leaflets.

Ensure that people can obtain information
on the correct use of condoms,
e. g. through free, illustrative
leaflets that do not require the user
to be able to read.

Both men and women should be encouraged
to insist that their partners
use a condom.

In any condom campaign, it is important
to make clear that the regular use of condoms
can help reduce the risk of HIV
transmission; however; they are not fully
reliable. They may tear, come off, or they
may even have holes (future issues of
AIDS Action will deal with the most reliable
brands of condoms).

Choose messages carefully

Avoid using fear. Fear of AIDS,
when combined with ignorance,
can encourage misunderstandings
about who is at risk and why.
People will often respond to
frightening messages by laughing them off or denying them. Your
message should be one of reassurance
that the disease can be
prevented. If you do use mild fear
tactics, always include clear statements
about the actions people
can take to reduce the risk of getting
AIDS, and where they can go
for advice.

Advertise safer sex as something
worthwhile, exciting and pleasurable,
rather than an inferior version
of ordinary sex. Be positive in
your advice.

Make your message as clear as
possible; Use local expressions for
words meaning sexual intercourse,
oral sex, anal intercourse,
penis, semen, vagina. For example,
in some parts of Africa, condoms
are referred to as 'gumboots' or
'raincoats'.

You do not need to describe the
complicated details of the virus
that causes AIDS, or of the immune system in order to justify the
safer sex message. Build on concepts
of disease and family values
that the community already understand.

Evaluate and share your experiences with others
We are still building up experience an
how health education can best be carried
out in the struggle against AIDS.
Sexual behaviours are extremely difficult
to change and are influenced by
a range of economic, social and cultural
factors. Be prepared to share your experiences and to evaluate and
modify your programmes.

*Basing health education campaigns on the use
of condoms, for example, will not be acceptable to some communities and their leaders. Do not
risk losing their cooperation by initially placing
too much emphasis on condom promotion.
Concentrate first on building up mutual trust,
and provide positive advice on other aspects of
safer sex that might be more culturally acceptable and practical. (Editor)

Readers are encouraged to send in their
reactions to this, and other; articles on health
education in AIDS Action based on their
own experiences.

Facing AIDS in Costa Rica

Costa Rica is one of the smallest countries in Latin America, with a population of 2.8 million. Over the last decade, its health services have radically reduced
mortality from diarrhoeal and other infectious diseases. But now the country faces the threat of AIDS. Professor Leonardo Mata, President of the National
AIDS Commission of Costa Rica, reports.

A total of 16 cases of AIDS per million of population have been
recorded in Costa Rica (as of 31 December,
1987). By 31 Jan, 1988, a total of 47 cases of AIDS had been registered. These cases include
homosexuals
and haemophiliacs*. At present,
the disease is taking its greatest toll
among homosexual men: the first case was diagnosed in 1985, six more
in 1986, and a further 19 in 1981. About
55 per cent of haemophiliacs are infected
with HIV - one of the highest
levels recorded worldwide.

Since 1985, only preheated coagulation
factors, prepared from blood
known to be free from contamination
with HIV, have been imported and all
donated blood has been screened for HIV, using ELISA and confirmation
hyimmunoblot.
No AIDS cases have
been recorded among injecting drug
users (injecting drugs is not a common
practice in much of Latin America).

HIV infection
At present, only one case of heterosexually
transmitted full-blown AIDS has been recorded - in the sexual partner
of an infected haemophiliac. But the
country is expecting AIDS to became
a problem in the heterosexual population,
as is already the case in Honduras
and a number of Caribbean
countries. Only ten women are known
to be HIV antibody positive (two of
whom work as prostitutes). 1,500 prostitutes
have been tested (ELISA test)
and found to be negative.

Magnitude of the epidemic
Estimates of the number of AIDS cases
expected to arise between 1988-1992 are: 40 new cases in 1988; 72 in 1989;
118 in 1990; 178 in 1991 and 254 in
1992. These figures are high for a
country where the estimated population in 1992 is only 3.1 million. If these estimates are correct (and
assuming that, at anyone time, half the total
number of AIDS cases recorded will
have died) deaths from AIDS could exceed
mortality due to diarrhoeal and
other infectious diseases within five years. During 1987, a total of 80 deaths were recorded due to
diarrhoeal diseases
in the whole country; no deaths
due to polio or diphtheria were recorded.

Health education campaign
A national health education campaign
began in April 1985. A pamphlet
containing ten easily understood messages
was widely distributed throughout the country, and the messages
were printed in five major daily news-papers.
Television programmes covered basic issues, and AIDS
education is being incorporated into
the curriculum of secondary and high
schools.

Updates and recommendations from the World Health Organisation
and US Centers for Disease Control
were translated into Spanish for distribution
to medical professionals and
other health workers. Talks and workshops
are being given in heath and
biological science institutions.

Education about safer sex and the
distribution of condoms in gay discotheques
and other public places
began in November 1987. Most of the
above activities have been
coordinated by the National AIDS Commission
and its committees, with
significant collaboration with the media,
NGOs, volunteers and the general
public.

Fear and controversy
AIDS has generated more fear, misunderstanding,
conflict and controversy than any other health problem in recent
years. Neglect of its importance
during 1985-6, resulted in timid actions and lack of funds for prevention and
control activities. Lack of understanding
by health workers - including
doctors and microbiologists - resulted
in discrimination against patients in certain hospitals, and a refusal
to carry out examination of blood or
other body fluids.

AIDS is testing our ability to deal
with a social problem of great complexity,
which threatens to affect every
family. Achieving a balance between the rights of society and those of the
individual has been difficult. In the
long run, AIDS will test whether or not
our society can truly be regarded as
humane and civilised.

Professor Leonardo Mata is President
of the National AIDS Commission, at the Ministry of Health, Costa
Rica, and a member of the editorial advisory board of AIDS Action.

*Haemophiliacs suffer prolonged bleeding after
injury because the blood cannot clot; they receive blood products for treatment
- coagulation
factors - some of which have been
infected with HIV from infected blood donors.

The following resource list is the second in a regular series, with a particular focus on health education materials
on AIDS, produced in both developed and developing countries. Readers are encouraged to send in additional
examples of leaflets and other resources, produced in their own countries.

Teaching Materials

Learning about AIDS
A manual covering participatory health
education strategies for health educators
with a responsibility for adult education
about AIDS. Developed in the UK Using
group work, case studies and role play,
Learning About AIDS includes: guidance
on how to use participatory approaches to
AIDS education; medical information
about transmission and current therapies;
exercises to help adults learn about AIDS;
guidance on how to evaluate the effectiveness
of AIDS education and a resource list.Available from: AIDS Virus Education and
Research Trust (AVERT), P O Box 91, Horsham
RH13 7YR, UK Price: £3.95 plus
postage (e.g. up to £7.00 for air mail).

Teaching AIDS: Educational Materials
about AIDS for School Teachers By Dr John Sketchley. Pack of materials including:
training component (helps teachers handle AIDS related issues in the
classroom); information ( for teachers to
use as resource on relevant facts); activities
(for classroom use in graded age
groups). The pack consists of a folder containing
seven information and related activity
sheets with illustrations for class use.
Available from: BLAT Centre for Health
and Medical Education, BMA House,
Tavistock Square, London WC7H 9JP, UK Price: £3.50 plus postage.

Information Sources

Activities: An information clearinghouse,
covering tropical and communicable diseases
worldwide. The Bureau produces
AIDS Newsletter (see AIDS Action issue
1)
and AIDS and Retroviruses Update - a
monthly bibliography which groups by
subject annotations all the papers and articles
on AIDS and retroviruses located by
the Bureau in the previous month. Contains
an author index. All entries form part
of the AIDS Database and are searchable
electronically (see below). Annual subscription rate: £95.00 (overseas).

Activities: Misereor acts for the Catholic
Church in Germany, supporting community
development. It is a private, non-profit
making organisation, under the responsibility
of the German Bishop's conference. A
special programme on AIDS in developing
countries was started in April 1987 Working in close cooperation with the Medical
Mission institute
of Wurzburg (FRG) the main
objectives are:

AIDS information service for local communities
(including supporting AIDS Action)

identifying and implementing the most suitable
diagnostic test for HIV antibodies for use
in developing countries.

Books/Manuals

Puppets for Better Health: a manual
for community workers and teachers
By Gill Gordon. Describes, through words
and pictures, how puppets can be used for
health education in communities: could
easily be adapted for education around AIDS prevention. Explains how to create
stories that are locally appropriate, how to
make puppets and props for shows, preparation
of shows and follow-up of health
messages used.
Available from: MacMillan
Distribution Ltd, Houndsmills, Bosingstoke,
Hampshire RG27 2XS, UK Price
£7.50 plus postage.

What is AIDS? A Manual for Health
PersonnelA short booklet written to help health workers
respond to, and learn1eam about, AIDS.
Also available In French and Spanish.
Contains information about all the main
facts., and c1ear illustrations. Describes
very clearly how the virus is and is not
spread, and the need for compassionate
and sensitive care of patients.
Available
from Christian Medical Commission,
World Council of Churches, 750 route de
Femey; 1211 Geneva 20; Switzerland.
Price: Free of charge.

Newsletter / Leaflets

AIDS Health Promotion ExchangePublished by WHO/Global Programme
on AIDS, with the editorial and technical
collaboration of the Royal Tropical Institute, The Netherlands. Promotes the
change of innovative ideas and materials
on AIDS education activities, as well as programme evaluation. Aimed at health
communicators around the world. Includes
a 'Country Watch' section, which
describes a selection of AIDS activities in a
number of different countries. Available
free of charge from: Exchange, Health
Promotion Unit, WHO/GPA, 1277Geneva,
Switzerland.
'AIDS... it's new, IT'S DEADLY'
This is a good example of a clear, factual
Produced by the Ministry of Health,
Commonwealth of Dominica. Suitable for
both health care workers and the general.
Describes basic disinfection procedures with local chlorine-based disinfectant and gives a health centre number to
ring for further information.

'Love safely' Produced by the medical and health department,
The Gambia. Contains a very
good description of some of the major and
minor symptoms of AIDS, and has a very
clear section on transmission risks through
injecting, cutting, scarring or circumcision
with instruments that have not been properly sterilised, as well as risks through
sexual
intercourse with an infected person.
Also states: 'in this country blood for blood transfusions
is being tested (for HIV infection)
before being given to patients'.

Drawings from 'Love Safely' leaflet (see
text). The first illustrates warnings about the
risk of spreading AIDS through injecting,
cutting, scarring or circumcision with
unsterilised needles and knives. The second, promotes the use of condoms.

International Symposium

Ixtapa, Mexico, will be the site of the First International Symposium on
Communication
and Education on AIDS, from 16-20 October,
1988. The symposium is being organised by the Ministry of Health of
Mexico, the World Health Organisation
and the Pan-American Health Organisation. Address enquiries to:

WHO Report - Special Programme on AIDS

The London Summit of Health Ministers met on 26-29 January 1988, to discuss AIDS prevention
and control. One hundred and
forty-eight countries were represented a,
with 114 Ministers of
Health in attendance, an unprecedented
number of ministers
attending any meeting on any subject. Ninety-eight ministers or heads of delegations spoke on
behalf of their countries' AIDS
prevention and control efforts.
The summit proclaimed 1988
Year of Communication and
Cooperation to Combat AIDS,
and adopted the following
declaration:

Since AIDS is a global problem that
poses a serious threat to humanity, urgent
action by all governments and people the
world over is needed to implement WHO's
Global AIDS Strategy as defined by the
Fortieth World Health Assembly and supported
by the United Nations General Assembly.

We shall do all in our power to ensure
that our governments do indeed undertake
such urgent action.

We undertake to devise national programmes
to prevent and contain the spread
of human immunodeficiency virus (HIV)
infection as part of our countries' health systems.
We shall involve to the fullest
extent possible all governmental sectors and relevant non governmental
organisations
in the planning and implementation
of such programmes in conformity with the
Global AIDS Strategy.

We recognise that, particularly in the
absence at present of a vaccine or cure for AIDS,
the single most important component
of national AIDS programmes is information
and education because HIV transmission
can be prevented through
informed and responsible behaviour. In
this respect, individuals, governments, the
media and other sectors all have major
roles to play in preventing the spread of
HIV infection.

We consider that information and education
programmes should be aimed at the
general public and should take full
account of social and cultural patterns, different
lifestyles, arid human and spiritual values. The same principles should apply
equally to programmes directed towards
specific groups, involving these groups as
appropriate. These include groups such
as: policy makers; health and social service
workers at all levels; international travelers; persons whose practices may
place them at increased risk of infection;
the media; youth and those that work with
them, especially teachers; community and religious leaders, potential blood donors
and those with HIV infection, their relatives
and others concerned with their care, all of
whom need appropriate counselling.

We emphasise the need in AIDS
prevention programmes to protect human
rights and human dignity. Discrimination
against, and stigmatisation of, HIV-infected
people and people with AIDS undermine public health and must be
avoided.

We urge the media to fulfill their important
social responsibility to provide factual and balanced information to the general
public on AIDS and on ways of preventing its spread.

We shall seek the involvement of all relevant governmental sectors
and non-governmental organisations in creating the supportive social
environment needed to ensure the effective implementation of AIDS
prevention programmes and humane care of affected individuals.

We shall impress an our governments
the importance for national health of
ensuring the availability of the human and
financial resources, including health and
social services with well-trained personnel,
needed to carry out our national AIDS
programmes, and in order to support
informed and responsible behaviour.

In the spirit of United Nations General
Assembly Resolution A/42/8, we appeal:
to all appropriate organisations of the
United Nations system, including the
specialised agencies; to bilateral and multilateral
agencies and to nongovernmental
and voluntary organisations, to support
the worldwide struggle against AIDS in
conformity with WHO's global strategy.

We appeal in particular to these
bodies to provide well-coordinated support
to developing countries in setting up
and carrying out national AIDS programmes
in the light of their needs. We recognise
that these needs vary from country to
country in the light of their epidemiological
situation.

We also appeal to those involved in dealing
with drug abuse to intensify their tries to learn from the experiences of
efforts in the spirit of the International Conference on Drug Abuse and Illicit
Trafficking
(Vienna, June 1987) with a view to contributing to the reduction in the spread of
HIV infection.

We call on the World Health Organisation,
through its Global Programme on AIDS, to continue to: exercise its mandate
to direct and coordinate the worldwide
effort against AIDS; promote, encourage
and support the worldwide collection and
dissemination of accurate information on
AIDS; develop and issue guidelines on the
planning, implementation, monitoring and evaluation of information and education
programmes, including the related
research and development, and ensure
that these guidelines are updated and
revised in the light of evolving experiences;
support countries in monitoring and
evaluating preventive programmes, including information and education
activities, and encourage wide dissemination of the findings in order to help
countries from the experiences of others.

Following from this Summit, 1988 shall be a Year of Communication about AIDS in
which we shall:

open fully the channels of communication in each society so as
to inform and educate more widely, broadly and intensively;

strengthen
the exchange of information and experience among all countries;
and

forge, through information and education and social
leadership, a spirit of social tolerance.

We are convinced that, by promoting
responsible behaviour and through international
cooperation, we can and will now
begin to slow the spread of HIV
infection.

Social aspects of AIDS
prevention and control

National
AIDS prevention and control programmes throughout the world operate in
substantially different epidemiological, social, economic and political
environments. However they have been faced with a similar range of complex
social issues, involving screening, employment, housing, access to health
care and schooling.

In the light of the experience of
national programmes to date, as well
as current knowledge about HIV infection
and AIDS, WHO/GPA wishes to
draw attention to the following social
aspects of AIDS prevention and control:

AIDS prevention and control strategies
can be implemented effectively and efficiently
and evaluated in a manner that respects
and protects human rights.

There is no public health rationale to
justify isolation, quarantine, or any discriminatory
measures based solely on the
fact that a person is suspected or known
to be HIV infected. The modes of HIV
transmission are limited (sex, blood,
mother-to-child). HIV spreads almost entirely
through identifiable behaviours and
specific actions which are subject to
individual control. In most instances, the
active participation of two people is required
for HIV transmission, such as in
sexual intercourse and in sharing contaminated
needles or syringes. However;
spread of HIV can also be prevented
through the health system (e. g. by ensuring
the safety of blood, blood products,
artificial insemination and organ transplantation,
and preventing re-use of
needles, syringes and other skin-piercing
or invasive equipment without proper
sterilisation.

HIV infection is not spread through
casual contact, routine social contact in
schools, the workplace or public places,
nor through water or food, eating utensils,
coughing or sneezing, insects, toilets
or swimming pools. Accordingly, an AIDS prevention and
control strategy should include:

providing information and education
to the general public, to persons with
behaviours that place them at risk of
HIV infection (risk behaviour groups),
and to HIV infected persons

counselling of HIV infected persons

ensuring the safety of blood and
blood products, skin piercing practices
and other invasive procedures.

In accordance with this strategy, persons
suspected or known to be HIV infected
should remain integrated within society
as much as possible and be helped to assume responsibility for preventing HIV
transmission to others. Exclusion of persons
suspected or known to be HIV infected
would be unjustified in public health terms and would seriously jeopardise educational and other efforts
to prevent the spread of HIV. Furthermore,
discriminatory measures create additional problems and cause unnecessary human suffering.

The avoidance of discrimination
against persons known, or suspected to be, HIV infected is important for
AIDS prevention and control. Failure
to prevent such discrimination may
endanger public health.

3. Testing
for the purpose of determining
an individual's HIV-infection status
should involve informed consent and
counselling and should ensure confidentiality.
Determination of an individual's
HIV-infection status may occur
through medical examination for suspected
HIV-related illness, voluntary
testing programmes, screening of blood
donors, or in other settings.
The Global Programme on AIDS has already published criteria (1) for HIV screening programmes which
emphasise
the need to consider carefully the public
health rationale for such screening as
well as to address explicitly the technical, operational, economic, social, legal and ethical issues inherent in screening
programmes.

This statement is available in leaflet form from WHO/GPA and may be up-dated on
the basis of additional experience with AIDS prevention and control programmes
worldwide, and as additional knowledge about HIV infection and AIDS becomes
available

The national planning process

The Special Programme an AIDS (SPA) was formally established
by WHO an 1 February 1987 (now renamed Global Programme an AIDS/GPA) and assigned the responsibility
of urgently mobilising national and international energies and resources
for global AIDS prevention and control.
The 40th World Health Assembly
(May 1987) urged all member states to
establish or strengthen AIDS prevention
and control programmes in cooperation
with GPA, as did the United
Nations General Assembly, at its 42nd
session in New York (October 1987).
To date, over 130 countries have
requested collaboration with GPA in
developing national plans.

It is intended that all support to
national AIDS prevention and control
programmes be coordinated and
directed under those programmes. It is
also intended that the establishment
of national plans represents an invitation
and opportunity for all institutions
active in a country to participate,
according to their strengths, in the
effort to control the spread of HIV
infection and to care for those afflicted
with AIDS. An overview of the national
planning process is presented below.

Formation of a National AIDS
Committee
The formation of a National AIDS Committee (NAC) is the first critical
step in the development of an AIDS
prevention and control programme. It
is the concrete expression of national
willingness to confront the complex
problems associated with HIV infection.
Furthermore, it provides the
mechanism for development of all
comprehensive activities required to
prevent and control AIDS.

The NAC should really act as an
advisory body to the Ministry of Health,
considering all aspects of programme
development and implementation,
including legal, ethical, managerial, financial and international issues as
well as technical considerations. The composition of the NAC should
be broad enough to ensure representation from all important sectors and organisations
of society.
The NAC decides on basic principles
and a plan of action to which the
programme will adhere, guiding the
future development of strategies and
activities. Clearly, the approach will
differ from country to country.

Nevertheless, there are certain issues
which arise in nearly all countries which
will need to be considered by the NAC
and which may warrant explicit policies.
These include:

surveillance and reporting of AIDS
cases and persons infected with
HIV in the country;

counselling of HIV infected persons,
AIDS cases, their families and other
contacts, including deciding on
who will be informed of test results
(i.e. the issue of confidentiality);

distribution of programme responsibilities
through intersectoral
cooperation, involvement of non-governmental
organisations (NGOs) and the use of the existing health
infrastructure and resources.

Short-term plan
An initial epidemiological assessment
is required to review and critically
analyse existing country data on HIV infection and AIDS cases and, where
necessary, to collect and analyse new
information.

An initial resources assessment is
required to determine the ability of the
existing health services to support
the epidemiological, educational,
laboratory, clinical and preventive
components of a national AIDS programme.

Resource assessment considers the
availability of resources from the
private sector, NGOs, volunteer, government and international organisations.
Areas considered include:
epidemiological surveillance; laboratory diagnosis, equipment and supply;
patient diagnosis, care, treatment and
management; education and training
of health workers at all levels of the
health services; blood banking and transfusion systems; resources for
counselling of patients; organisations which can participate in public health
communication and education programmes;
policies and practices for use
and reuse of needles, syringes and
other surgical and dental instruments, lancets to diagnose malaria and other skin-piercing instruments wherever
used; communication information and education systems, and legislation.

These initial epidemiological and
resource assessments typically result in an immediate short-term plan to
provide urgently required support.

Medium-term plan
A medium term programme (MTP)
serves two important purposes: it acts
as a tool for the implementation of the
national control programme and identifies
what activities will be carried out - where and when, at what cost, and persons to be responsible
- and it
forms a document which can be used for the mobilisation of external funds.

The medium term is assumed to be
three to five years. However, given the
uncertainty surrounding the future course of AIDS, it is unlikely that any
country will be able to prepare a MTP
which will not require revision during
this time period.

prevention of perinatal transmission,
involving the training of health care providers and a variety of
targeted information, education and counselling programmes.

In addition, planning must provide
for the care of AIDS patients and
reduction of the impact of HIV infection
on individuals, their families and
their communities. Since plans for
health care workers, training, health
promotion and evaluation need more
than one strategy, these are sometimes treated in separate sections of
the National Plan. A full description of
GPA recommendations for planning is
available in Guidelines for the
Development of a National AIDS Prevention and Control Programme
(WHO/GPA).

In support of this planning process,
WHO/GPA has assisted in the preparation
of 75 short-term plans and 21
medium-term plans. Immediate support
has been provided for 71 countries,
involving technical services agreement or other form of technical
and financial support.
AIDS Surveillance Report
The
global total of reported cases of AIDS, as of 10 February, 1988, is 77.984 from
162 countries.
AIDS has been reported from every
part of the world:

Continent

Number of
cases

Countries or territories
reporting cases

Africa

8,752

48

Americas

59,217

44

Asia

225

28

Europe

9,004

28

Oceania

786

14

Total

77,984

162

Lack of reporting and widespread under-recognition and under-diagnosis of AIDS
means that the number of reported cases is
a marked underestimate of the true incidence
of AIDS. WHO estimates that as of
late 1987, approximately 150,000 cases of
AIDS have actually occurred worldwide.
Eve n these estimates do not adequately describe the current clinical burden caused by
HIV because AIDS cases represent only the
end-stage of severe and irreversible damage due to HIV infection.

Any questions about the content of the WHO Report should be sent to WHO/GPA/HPR, 20 Avenue Appia, 1211 Geneva 27, Switzerland

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